Basic Information
| Provider Information | |||||||||
| NPI: | 1306841168 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GIST | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | G | ||||||||
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| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CARR | ||||||||
| OtherFirstName: | JENNIFER | ||||||||
| OtherMiddleName: | G | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 865 LINCOLN RD | ||||||||
| Address2: | STE L10 | ||||||||
| City: | BETTENDORF | ||||||||
| State: | IA | ||||||||
| PostalCode: | 527224159 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5633559191 | ||||||||
| FaxNumber: | 5633553419 | ||||||||
| Practice Location | |||||||||
| Address1: | 865 LINCOLN RD | ||||||||
| Address2: | STE 200 | ||||||||
| City: | BETTENDORF | ||||||||
| State: | IA | ||||||||
| PostalCode: | 527224159 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5633448600 | ||||||||
| FaxNumber: | 5633442967 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2005 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 33452 | IA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | IA0132 | 01 | JOHN DEERE HEALTH PLAN | OTHER | 059729 | 01 | HEALTH ALLIANCE | OTHER | 152589 | 01 | IOWA HEALTH SOLUTIONS | OTHER | 29717 | 01 | IA | WELLMARK BC/BS | OTHER | 1207886 | 05 | IA | MEDICAID |